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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;. (Complete in Triplicate) Application is hereby made to the San Joaquin Local-Health pistfict for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .Y Job Address dQ�� _ RAI .1 City Lod i Lot Size /O ACHAFS PM. Owner's Nam >w Address Phone Contractorc O S Address Q •� License No Phone 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAgEMENT ❑ `,'�Z:�DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'IV%1 tl_L PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ 4 Well Destruction ❑ Well Diameter Sealing Material (top 50')""-"�_ �� f�___ ��._� /It✓,1 Depth ; Filler Material (Below 501 if TYPE OF SEPTIC WORK: NEW INSTALLATION ■ REPAIR/ADDITION E-DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet;) Installation will serve: Residence Commercial_ Other " ^ Number of living units: A— Number of bedrooms. r �J Character of soil to a depth of 3 feel: A„'1 Water table depth SEPTIC TANK ■ Type/Mfg rJ nR. _ Lapacity_2- No. Compartments Z 1 PKG. TREATMENT PLT. ❑ f f Method of Disposal J Distance to nearest: Well Fou �tion 1 D Property Line r LEACHING LINE No & Length so#�lines ? ^� Total length/size ~� r1 9 ✓ FILTER BED El Distance to nearest: Wel lFoundation I`-'". Proper�Line SEEPAGE PITS Q Depth Size W Number SUMPS ❑ Distance to nearest,. -"*Well Foundation""° Property Line `/xJ DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state,laws, and rules and regulations of the San Joaquin Local Health District. 4# t). 4 .�,,,At Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ! The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area_ r �� Pit or Grout Inspection by Date Final Inspection by Date c �a y Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95W1 l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.i/0A5) __70 EH 14-28 - `